Schizophrenia relapse

The cornerstone of treatment is antipsychotic medications. Because most patients with schizophrenia relapse when not medicated, long-term treatment is usually necessary. 

Sellers EM, Naranjo CA, Harrison M, et al Diazepam loading simplified treatment of alcohol withdrawal. Clin Pharmacol Ther 34 822-826, 1983 Sharp CW Introduction to inhalant Abuse, in Inhalant Abuse A Volatile Research Agenda (NIDA Research Monograph 129). Edited by Sharp CW, Beuvais F, Spence R. Rockville, MD, National Institute on Drug Abuse, 1992, pp 1-10 Smelson DA, Losonczy MF, Davis CW, et al Risperidone decreases craving and relapses in individuals with schizophrenia and cocaine dependence. Can J Psychiatry 47 671-675, 2002... 

Since early detection and intervention in schizophrenia is important for maximizing outcomes, treatment with antipsychotic medications should begin as soon as psychotic symptoms are recognized. Antipsychotic medications are the cornerstone of therapy for people with schizophrenia, and most patients are on lifelong therapy since non-adherence and discontinuation of antipsychotics are associated with high relapse rates. If other symptoms are present such as depression and anxiety, these symptoms should also be aggressively treated. Additionally, psychosocial treatments should be used concomitantly to improve patient outcomes. 

Yui, K., Goto, K., Ikemoto, S. et al. Neurobiological basis of relapse prediction in stimulant-induced psychosis and schizophrenia the role of sensitization. Mol. Psychiatry. 4 512, 1999. 

Akiyama, K., Kanzaki, A., Tsuchida, K., Ujike, H. Methamphetamine-induced behavioral sensitization and its implications for relapse of schizophrenia. Schizophrenia Res. 12 251, 1994. 

However, when there is clear evidence of persistent illness or when the patient endures several acute episodes of illness, treatment shonld be indefinite and probably lifelong. Except in the residual phases of illness, discontinuing antipsychotic medication exposes the schizophrenia patient to a serious risk of relapse. However, there is evidence that gradually decreasing the dose of antipsychotic in 4 week intervals can still provide good protection from relapse while lowering the risk of side effects. 

Maintenance Evaluation of patients with schizophrenia who had been stable on other antipsychotic medications for periods of 3 months or longer, were discontinued from those medications, and were then administered aripiprazole 15 mg/day and who were observed for relapse for up to 26 weeks demonstrated a benefit of such maintenance treatment. Periodically reassess patients to determine the need for maintenance treatment. 

Reports of efficacy in acutely relapsed schizophrenia and schizoaffective disorder, and has an improved tolerability profile compared to haloperidol... 

The families of children and adolescents with schizophrenic psychoses have to be included in the planning and design of therapy. Empirical research has shown, however, that ambitious family therapy designs have not reaped the benefits hoped for. Studies using the concept of expressed emotion have shown that emotional factors within the family play an important role in relapses of the disorder. Therefore, in every child and adolescent with schizophrenia, one must decide on the extent to which the family should be integrated into the therapeutic process. This depends on the patient. 

Hoggarty, G.E., Anderson, C.M., Reiss, D.J., Kornblith, S.J., Green-wald, D.P., Javna, C.D., and Madonia, M.J. (1986) Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia. I. One-year effects of a controlled study on relapse and expressed emotions. Arch Gen Psychiatry 43 633-642. 

The 2004 Practice Guideline for the Treatment of Patients With Schizophrenia recommends indefinite maintenance treatment for patients who have had at least two episodes of psychosis within 5 years or who have had multiple previous episodes (Lehman et al. 2004). Maintenance therapy should involve the lowest possible doses of antipsychotic drugs, and patients should be monitored closely for symptoms of relapse. If the patient is compliant with treatment, oral medications are usually sufficient. However, if the patient s treatment history suggests that the patient may not reliably take daily oral medication, a long-acting depot preparation may be indicated. 

Schooler NR, Keith SJ, Severe JB, et al Relapse and rehospitalization during maintenance treatment of schizophrenia the effects of dose reduction and family treatment. Arch Gen Psychiatry 54 453-463, 1997... 

In a double-blind, multicenter, prospective study, Csernansky et al. (2002) showed that among patients with clinically stable chronic schizophrenia or schizoaffective disorder the risk of relapse was significantly lower with risperidone than with haloperidol (34% vs. 60%, P < 0.001). The means of daily doses of risperidone ( 4.9mg) and haloperidol (11.7mg) were similar to those used in clinical practice (Csernansky et al.y 2002). The reduced risk of relapse found with risperidone could be due to its superior efficacy, better tolerability or both (Csernansky et al.y 2002). 

Muller and Schoneich (1992) also reported on favorable experience with intensive outpatient psychotherapy combined with antipsychotic drug treatment. On the basis of a before-and-after comparison over 2x5 years in a university outpatient clinic, they were able to show that the duration of rehospitalizations required by 89 patients could be reduced from a mean of 10 weeks to 2 weeks per year when a special schizophrenia outpatient service offering individualized psychotherapy and psychosocial treatment was available to the patients instead of the routine psychiatric outpatient service. A beneficial effect of psychotherapy was demonstrated both in those patients taking antipsvchotics continuously for long-term prophylaxis and in those taking the drugs intermittently when prodromal symptoms appeared in order to prevent relapse. 

Jorgensen, P. Early signs of psychotic relapse in schizophrenia. Br. J. Psvchiatrv 172, 327-330, 1998. 

Chapter /, Modem Psychopharmaceuticals, written by Dr Hossein Fatemi, and Chapter 5, Psychopharmaceuticals and the Treatment of Mental Disorders, provide succinct, up to date, and well-referenced information on how to use the major classes of psychotropic drugs. The latter chapter discusses in a frank and balanced manner the ambivalence towards the use of pharmacologic agents in mental disorders felt by some, and the limitations on the achievements of current drugs as ideal therapies for schizophrenia, bipolar disorder and major depression in particular. Clearly, much has been accomplished, but many needs, especially for prevention of relapse, removal of specific types of symptoms, and restoraton of work and social function, remain to be accomplished by drug and psychosocial therapies. 

Hunt GE, Bergen J Bashir M (2002). Medication compliance and comorbid substance abuse in schizophrenia impact on community survival 4 years after relapse. Schizo-prenia Research, 54, 253-64... 

Swofford CD, Kasckow JW, Scheller-Gilkey G Inderbitzin LB (1996). Substance use a powerful predictor of relapse in schizophrenia. Schizophrenia Research, 20, 145-51... 

Mantel-Haenszel test, the combined studies indicated a highly significant difference (c - 483 df = 1 p < 10 This finding represents overwhelming statistical evidence that in schizophrenia, antipsychotics prevent relapse. 

FIG. 5-6. Relapse rate of schizophrenic patients after 24 months on placebo. (From Prien RF, Cole JO, Belkin NF. Relapse in chronic schizophrenia following abrupt withdrawal of tranquilising medication. Br J Psychiatry 1969 115 679-686, with permission.)... 

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